formulir pendaftaran - sampoerna academy year end camp

7/28/2019 Formulir Pendaftaran - Sampoerna Academy Year End Camp

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Sampoerna Academy Headquarter

Sampoerna Strategic Square, North Tower, Lantai 27 Jl. Jenderal Sudirman Kav. 45 Jakarta 12930

Tel. (021) 577 2340 Fax. (021) 577 2341 | www.sampoernafoundation.org

SAMPOERNA ACADEMY YEAR END CAMP

SABTU, 15 16 December 2012

Kinasih Resort, Jl. Raya Sukabumi No. 17, Caringin - Bogor

FORMULIR PENDAFTARAN

Yang bertanda tangan di bawah ini:

Nama Orang Tua : ..

Nama Anak :

Tanggal Lahir :

Alamat :

No. kontak :

Dengan ini menyatakan setuju untuk mengisi formulir pendaftaran dan formulir kesehatan yang telah disediakan

serta memberikan izin kepada (nama anak) untuk menjadi peserta Sampoerna Academy Year EndCamp 2012. Saya mengetahui dan memahami tata tertib/persyaratan yang telah ditetapkan oleh Sampoerna

Academy dan saya memberikan wewenang kepada penyelenggara untuk mengambil tindakan yang diperlukan

demi kalancaran acara.

Peserta membawa Rp 150,000 (seratus lima puluh ribu rupiah) dan diserahkan pada panita saat registrasi ulang

(akan digunakan untuk kegiatan Community Service Giving Back to Society saat camp)

Transportasi yang akan peserta gunakan menuju lokasi Year End Camp:

Diantar keluarga menggunakan kendaraan pribadi

Shuttle bus yang disediakan panitia di Sampoerna Strategic Square - Jl. Jenderal Sudirman Kav. 45Jakarta 12930

Tandatangan, Tanggal & Nama Jelas

Harap formulir ini dan health form (di bawah ini) segera diisi dan dikirimkan ke:

A-Z Communications [[email protected]]CP: Rina 085782077555

Save file as: Daftar SA Camp (Nama peserta)

Terima kasih.


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PARTICIPANT HEALTH FORMSampoerna Academy Year End Camp 2012

__________ __________ _________ ____________ _______ ______

SURNAME First Middle Date of Birth F/ M Blood group

Is the student on long term medication? YES / NO

Does the student take medication during school hours? YES / NO

Please list the name of the medication and the frequency

Are there any known drug allergies?

Please list the names of drug allergies:

Parents Name : _____________________________________________________________

Home address : _____________________________________________________________

Home Phone number : __________________________________

Office address : ______________________________________________________________

Office Phone number : __________________________________

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HEALTH ADMISSION DETAILS :

Current Tuberculin Skin Test or X- Ray result within last twelve months. This is an annual recommendation.

TB Skin test Result Date Chest X - Ray Result Date

Fill in : normal or not normal. If the result was not normal please explain:

BCG inoculation : YES date :

NO

Does the student wear glasses or contact lenses? YES/NO

Date of last vision test ___________________________

Date of last hearing test __________________________

IMMUNIZATIONS : DATE OF LAST BOOSTER OR VACCINATION :

Diphtheria/Tetanus/whooping cough _________________ Polio ____________________

Tetanus (every 10 years) ____________________________ Measles __________________

Typhoid injection (every 3 years) ______________________ Rubella __________________

Typhoid oral (every year) ____________________________ Others ___________________

Mumps _________________________________________

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These health conditions can be a concern. Please circle any that apply to your child.

Allergies, Asthma, Congenital anomalies, Convulsions/Epilepsy, Diabetes, Recurring ear infections, Hearing

difficulties, Frequent headaches, Heart problems, Kidney/ Urinary infection, Menstrual problems,

Orthopedics problems, Operation convalescence, Rheumatic fever, Skin problems, Tuberculosis, Visualproblems, Others.

Please comment on circled items:

_____________________________________________________________________________________

___________________________________________________________

Explain any limitation on physical activity:

_____________________________________________________________________________________

_____________________________________________________

PERMISSION IS HEREBY GIVEN FOR EMERGENCY MEASURES TO BE INITIATED IN CASE

OF ACCIDENT OR SUDDEN ILLNESS WITH THE UNDERSTANDING THAT I WILL BE

NOTIFIED. I CERTIFY THAT ALL INFORMATION GIVEN ON THIS CARD IS COMPLETE AND

CORRECT.

Signature of Parent : ________________________________date _____________________________

Please insure that the school is informed of any changes to the information on this documentation.

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formulir pendaftaran - sampoerna academy year end camp

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